Now what? - GPMHSC

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Now what? Suicide safety planning in general practice

Introduction

Safety planning provides a structured approach that empowers people to manage psychological distress and suicidal thoughts, thus aiming to reduce their immediate risk of engaging in suicidal behaviour.²⁵ It involves the person – ideally with support from a health professional – identifying coping and help-seeking strategies that are tailored for their needs, situation and personal relationships. The resulting safety plan is then used during times of distress and crisis.

When to do a safety plan

A safety plan can be a useful therapeutic tool when someone is ambivalent about living or dying, whether these thoughts are vague or intense in nature, as it can help to contain distress and offer ideas for improving their mental health. Safety planning is most pertinent when a GP understands the risk of suicide to be serious in nature.

An appointment with a GP might be the first and only contact that the person has with a health professional and as such, offers a unique opportunity to influence a person’s safety and begin to create a roadmap for improving their mental health.

Documenting a safety plan

A safety plan can be documented on a paper template or via e-resources such as websites or apps. The BeyondNow app provides a simple-to-use tool for people to refer to on their phones (download at the Apple App Store or Google Play), or to complete online and email to themselves.

BeyondNow gives people access to their safety plan whenever they feel their level of distress increasing. They can refer to their safety plan at any appointments with their health professionals and share it with their family and close friends.

Start by downloading the app from the Apple App Store or Google Play and familiarising yourself with it. You can also check out a quick introduction here, to the different features, including editing and sharing a plan.

Apps might not be for everyone, so first consider whether using an app for safety planning is appropriate for your individual patients. It is then important to consider how you are going to introduce it to your patients; including information about the strengths and limitation of the app, when they might use it, as well as a reminder that this is a confidential plan that they can choose to share with those they find supportive.

Key steps of safety planning

When you’re supporting your patient to create their plan, asking questions can help them think about what might work for their situation and ensure the identified strategies meet their individual needs.

Below are a range of questions that seek to find the key information for a safety plan. The BeyondNow app, and some associated information on the beyondblue website, also provides these prompts to assist with the completion of the plan.

1. Recognising warning signs and personal triggering events

Being aware of changes in thoughts, moods and behaviour that may signal a developing crisis allows the person to act earlier, helping to reduce further risk.

Questions to ask might include:	Warning signs might include:
How will you know when your safety plan should be used? What are some of the difficult thoughts, feelings or behaviours that you experience leading up to a crisis?	Moods such as sadness, anxiety or irritability. Thoughts involving hopelessness, helplessness, or self-criticism. Behaviours such as drinking more alcohol than usual, avoiding social situations, or arguing more often with friends or loved ones.

2. Creating a safe environment

Identifying ways of keeping the person’s immediate environment safe can be achieved by reducing or eliminating their

Questions to ask might include:	Restricting access to lethal means might include:
Are there any specific situations or people that you find stressful or triggering, or that contribute to your suicidal thoughts? What things do you have access to that are likely to be used in a suicide attempt? How can we develop a plan to limit your access to these means and avoid these situations?	Asking someone else to manage access to medication. Reducing access to firearms or improving safety procedures. This step should always involve having a support person remove any firearms. Getting rid of glass or blades that might be used to cause harm.

3. Identifying reasons to live

Developing a list of positive things in life that bring joy and meaning or something to look forward to can help to change the client’s focus.

Questions to ask might include:	Reasons to live might include:
What’s the best thing about living? What’s the most important thing in your life? What things in your future do you look forward to?	Family, friends or pets. Spiritual or religious beliefs. Everyday pleasures such as walking on the beach or enjoying nature. Life experiences such as having children or travelling.

4. Things I can do by myself – internal coping strategies

Identifying activities and internal coping strategies that an individual can do without contacting anyone else. These activities/strategies can help to regulate their emotions, reduce distress, change the focus of their thinking, and distract themselves from suicidal ideation, potentially preventing a further escalation into crisis.

Questions to ask might include:	Internal coping strategies might include:
What can you do on your own if you have suicidal thoughts in the future, to avoid acting on those thoughts? What can you do to help take your mind off your problems, even for a short amount of time?	Breathing or relaxation exercises. Going for a walk, doing yoga or other exercise. Watching a favourite movie or listening to a favourite band. Playing or cuddling with a pet.

5. Socialisations strategies for distraction and support – connecting with people and places

Just being around other people can help provide distraction from suicidal thoughts – this can include spending time with family and friends, or going to a busy park or shopping centre.

Questions to ask might include:	Socialisation strategies might include:
Who helps you to feel good when you socialise with them? Where can you go and be around other people in a safe environment?	Spending time with friends and family, remembering that socialising can also include activities that don’t require much talking or engagement (eg watching TV). A coffee shop, park, place of worship or meeting group.

6. Trusted contacts for assisting with a crisis – friends and family to talk to

The person should think carefully about who would be helpful in a crisis, and avoid listing people who could possibly exacerbate the situation.

Questions to ask might include:
Among your friends and family, who do you feel you could talk to when you’re having suicidal thoughts? Who do you feel you could contact to support you during a suicidal crisis?

7. Professional contacts for assisting with a crisis

Questions to ask might include:
Which services could you turn to for support? What health professionals can you involve in your treatment plan?

Some people may not wish to complete a particular step or steps in the safety plan. Their plan is unique to them and is all about keeping safe, so if certain steps aren’t helpful or create an additional source of burden, stress or conflict, these can be left out.

Safety plans are designed to be followed step by step. However, it’s important to reinforce with your client that if they feel at imminent risk and are unable to remain safe – even for a short period of time – they should phone or present to an emergency service.

Reviewing the safety plan

A safety plan should be modified over time to ensure its effectiveness. At a follow-up appointment GPs should ask their patient:

How often they have needed to use the plan?

What the most useful aspect of the safety plan was?

Were there any barriers to its use?

How they can continue to use the safety plan?

Safety planning is a practical and accessible strategy that can assist GPs to help patients to manage difficult emotions in a self-directed manner, while also guiding them as to when to seek out the support of other health professionals.

Safety planning resources

Patient safety plan template: Suicide Prevention Resource Center (USA), www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf

beyondblue video – offers an insight into how individuals have used safety planning on their road to recovery,
www.beyondblue.org.au/get-support/beyondnow-suicide-safety-planning

The below video is a documentary titled Suicide and Me. It includes personal reflections about experiences of suicidal thoughts and footage of what it’s like to work at a suicide helpline service. Please note, some information in this video may be distressing.

References

Melvin GA, Gresham D, Beaton S. Safety first – not last! Suicide Safety Planning Intervention (SPI). InPsych 2016; 38(1):14–15.
[Accessed 30 May 16].

Downloads

Suicide prevention and first aid a resource for GPs